Fishhook injuries are common, usually straightforward, and surprisingly under-discussed in emergency medicine education. Most of us learn fishhook removal by watching another clinician do one, removing a few ourselves, and slowly accumulating preferences over time. There are relatively few comparative studies, no major practice-changing trials, and not much formal teaching. Yet if you work in pediatric emergency medicine, urgent care, sports medicine, or primary care long enough, eventually somebody is walking into your room with a fishhook in a finger.

This post accompanies the latest episode of PEM Currents and reviews practical fishhook removal techniques, pain management, procedural considerations, and post-removal care in children.

Initial AssessmentFishhook injuries in children most commonly involve the hands and head and can generally be managed in the emergency department or urgent care setting with local anesthesia and basic equipment. The first step is not choosing a removal technique, it is understanding the injury.

Questions I think through before touching the hook include: Is this a single hook or a treble hook? Is the hook barbed? How deeply embedded is it? Is this near a tendon, joint, nerve, vessel, or the eye? Was the injury sustained in freshwater, saltwater, or out of water entirely? Has anyone already attempted removal?

A treble hook deserves special mention because it changes procedural planning. Treble hooks consist of three individual hook points and barbs fused to a single shank and eye. Even when only one point is embedded, the additional exposed hooks create opportunities for secondary injury to both patient and clinician during removal.

If there is concern for globe injury, stop. Fishhook injuries involving the eye are not routine emergency department procedures and warrant ophthalmology involvement.

Fishhook Removal TechniquesThere is not one “correct” fishhook removal technique. Four classic approaches are described in the literature and each has advantages depending on the anatomy and characteristics of the hook.

Retrograde TechniqueRetrograde removal is the simplest conceptually and is usually what families expect. Pull the hook back out the same direction it entered. This works best for barbless hooks or very superficial hooks where the barb has not fully engaged tissue. Unfortunately, most hooks encountered clinically are barbed. Once the barb catches tissue, simple backward traction usually increases pain and tissue distortion without successfully removing the hook. Because of that limitation, retrograde removal is often less successful for embedded fishhooks.

Advance-and-Cut TechniqueThis is probably the technique I use most often. Advance-and-cut sounds counterintuitive when you explain it to families because the plan is to continue advancing the hook rather than removing it immediately. Mechanically, however, it makes excellent sense. The hook is advanced through the skin until the barb exits completely. Heavy wire cutters are then used to remove the barb, allowing the remaining smooth portion of the hook to be withdrawn back through the original tract. The obvious tradeoff is creation of a second puncture wound. In practice, however, this additional wound is often less traumatic than repeated unsuccessful attempts at extraction. Children generally tolerate one good attempt significantly better than multiple failed attempts.

String-Yank TechniqueThe string-yank technique is widely demonstrated online and occasionally performed in field settings. String or heavy suture is looped around the bend of the hook while downward pressure is applied to disengage the barb. A quick pull parallel to the hook shaft removes the hook. When successful, removal is nearly instantaneous. The challenge in pediatrics is cooperation. This approach becomes more difficult in anxious children, younger children, deeply embedded hooks, and treble hooks.

Needle-Cover TechniqueThe needle-cover method receives less attention but remains useful in selected situations. An 18-gauge needle is inserted alongside the hook until the bevel covers the barb, and both are withdrawn together. The main advantage is minimizing tissue trauma and avoiding creation of a second puncture site. The downside is technical complexity. Maintaining alignment between the needle and hook can be challenging, particularly in smaller children.

Pain Management and Procedural SupportMost fishhook removals in children can be performed with local anesthesia alone. Lidocaine 1% with or without epinephrine is usually adequate. Depending on location, digital blocks or field blocks may be preferable to local infiltration because infiltration itself can distort tissue planes and complicate removal. One practical strategy worth considering is topical anesthetic before injection. LMX or EMLA can reduce the discomfort of local infiltration, particularly in anxious children. The limitation is timing. These agents generally require approximately 40 to 60 minutes for meaningful effect, so they only help if procedural planning starts early.

In children, procedural success is rarely determined by analgesia alone. Child life support, distraction, parental coaching, videos, music, and procedural preparation frequently determine whether a straightforward removal stays straightforward. Most children do not require procedural sedation, although anxiolysis with midazolam or inhaled nitrous oxide can be extremely helpful. Ketamine remains an excellent option for selected cases involving failed attempts, difficult anatomy, or children who cannot tolerate removal safely.

Antibiotics and AftercareFishhook removal does not automatically require antibiotics. A prospective study of 100 fishhook injuries found prophylactic antibiotics unnecessary for uncomplicated soft tissue injuries not involving cartilage or tendon. Situations where antibiotics deserve consideration include delayed presentation, gross contamination, tendon involvement, joint involvement, water exposure, or signs of established infection. Freshwater exposure raises concern for organisms such as Aeromonas. Saltwater injuries introduce consideration of Vibrio species and occasionally Mycobacterium marinum.

Once the hook is removed, wound management is generally simple. Irrigate the area, inspect for retained fragments, reassess neurovascular status and range of motion, apply a basic dressing, and review tetanus status. Families often ask when their child can fish again. Usually sooner than they expect. Maybe just avoid standing directly behind whoever is casting.

Take-Home Points* Fishhook removal is usually straightforward but benefits from deliberate technique selection. * Advance-and-cut is broadly reliable and often my preferred approach in children. * Local anesthesia is sufficient for most patients, though procedural planning and anxiolysis frequently determine success. * Routine antibiotics are unnecessary for uncomplicated injuries. * And if the hook involves the eye, that is no longer a fishhook removal problem, it is an ophthalmology problem.

ReferencesGammons MG, Jackson E. Fishhook removal. Am Fam Physician. 2001;63(11):2231–2236.

Prats M, O’Connell M, Wellock A, Kman NE. Fishhook removal: case reports and a review of the literature. J Emerg Med. 2013;44(6):e375-e380. doi:10.1016/j.jemermed.2012.11.058

Doser C, Cooper WL, Ediger WM, et al. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9(5):413–415. doi:10.1016/0735-6757(91)90204-w